Morrisey,Dawn A. Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME:
REQUESTED RETURN TIME:
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
NAME:
---- -- -pew as -_y
------------------ ----
ATE OF CREMATION:
TIME STARTED: /0.--cI
COMPLETED: ---- -�� 3D �......
TYPE OF CONTAINER: .__�'r v N ,C ND__ _._--
{
- -
ACED IN RETORT:
_._. __._.. .
PLACE OF DEATH: ------- j�O --- a Is}�`%���
ESTIMATED WEIGHT OF REMAINS AND CONTAINER: -
DATE & TIME REMAINS ARRIVED AT CREMATORY:
PLACED IN HOLD:
PLACED IN REFRIGERATION:
RETORT # IN WHICH REMAINS WERE CREMATED:
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 48 HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE CREMATION LOG SHALL BE RETAINED IN THE PERMANENT FILE OF THE CREMATORY.
I
New York State
1)epaltment of State
DIVISION or-CEMETERIES
One Commerce Plaza
n of 99 Washington Avenue
NEW YORK I)I S710 Albany,NY 12231-0001
Cemeteries
Telephone:(518)4746226
STATE OP Cerra
OPPORTUNITY. ww N.dos.ny.gov
tion for Cremation and Disposition
Authorriza
must be completed and signed prior to delivery of remains for cremation.
This Authorization Form 3 5
Number.
Date: 04/14/2020
Crematory Name: Pine View Crematory Phone: Slj 1`I'J
Address: 21 Quaker Rd., Queensbury. NY 12804
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS.
ntiner ding the remains into a cremation chamber where
Cremation is
carried out by placing the remains of the deans f ame and the
II incur ate anld consume everything except bone and metal,
they are subjected to intense heat and flame. The ea
which are all that will be left after cremation.
efforts to Followemation
ing cremation,the crematory v�ill take reasonable
will likely be left behind.remove
The matory will nseparate s and h incidental aner material rd foreignom the rmatena from
icalty
chamber, but some minimal dust and residue of
the remains and the incidental and foreign n aaterial will be des gnat d disposed
oma container oror urn.
pulverized remated remains generally are pulverized ains wil until nno
pulverized into small pieces and plac
single fragment is recognizable as skeletal tissue.
OPENING OF THE CONTAINER -cremated hump remains in limited circumstances,such as to confirm the
o en the container holding th
e un
The crematory may only p enclosed which night injure employees or damage the crematory property. H
no material is e
identity of the deceased or to
ens
ure that human remains are delivered in a container which is not suitable forcremation such as ceremonial or rental casket,the
le
ng of a
crematory rthe transferthat
o a the remains be moved removal of remains will bernto a conductedabef before container
Iitn ss and will be done in prre it accepts the ivacy,acy,with dignity
mains. The and respect
container or
IDENTIFICATION OF DECEASED �
Name of Deceased: Dawn A. MOrrlSey
Marital status: Married
Last Known Address: 36 Olmstedville Road, PO Box 1, Potters>ille, New York 12860
Place of Death: Deceased's Residence, 36 Olmstedville Road Pottersville, NY 12860
I
Sex: El M ® F Age: DO
B OB: 09/17/1957 Date of Death: 04/13/2020 Estimatedweight 120 I
Description of casket/container in which remains will be delivered.
New England Cremation deluxe container
i
PERSON IN CONTROL OF DISPOSITION
(Person(s)in control of disposition, initial ONE of the following)
I amNVe are the designated agent of the deceased designated in a will or written instrument executed pursuant to Public
Health Law Section 4201.
-OR-
W�'� IMe have no knowledge that the deceased executed a witten instrument pursuant to Public Health Law Section 4201 or
will containing directions for the disposition of his or her remains and Uwe are the person(s) having priority under Public Health Law
Section 4201 and have the right to authorize cremation of the remains of the deceased. MylOur relationship to the deceased is as
follows:
Dawn A. Morrisey
(Name of Deceased)
I
DOS-1898-f(Rev. 08/15) Page 1
Authorization for Cremation and Disposition
(Insert from the list below)
Number: 2 Description: Surviving Spouse
1. A person designated in writing pursuant to Public Health Law Section 4201(3);
2. The surviving spouse;
2a. The surviving domestic partner;
3. Any surviving child eighteen years of age or older;
4. A surviving parent;
5. A surviving sibling eighteen years of age or older;
6. A lawfully appointed guardian;
7. Any person(s)eighteen years of age or older entitled to share in the estate and who is/are closest in relationship to the deceased;
8. A duly appointed fiduciary of the estate;
9. A close friend or relative who has executed a written statement pursuant to Public Health Law Section 4201(7);
10. A chief fiscal officer of a county or a public administrator appointed pursuant to the Surrogate's Court Procedure Act;
10a. Any other person who is acting on behalf of the deceased and who has executed a written statement pursuant to Public Health
Law Section 4201(7).
(Initial ALL THREE of the following)
Wee- I/We hereby affirm that the body of the deceased does not contain a battery, battery pack, power cell, radioactive implant,
or radioactive device and that any such materials were removed prior to the execution of this Authorization Form. Failure to remove
these items prior to cremation may result in harm to the crematory and crematory personnel.
tNEi�"1 IMe affirm that instructions have been given to David Alexander
(Funeral Director Name)
regarding the removal of any personal property or other thing of value which any person signing below or any family member of the
Pine View Crematory
deceased wishes to preserve. (crematory Name)
is not responsible for the removal of personal items from the container or from the remains of the deceased. Personal items left in the
container or with the remains will be destroyed by the cremation process and cannot be retrieved after cremation.
IIWe hereby authorize Pine View Crematory
(Crematory Na—)
to cremate the remains of the deceased.
FINAL DISPOSITION
The person authorized to receive the cremated remains of the deceased from the crematory is:
Name: Alexander-Baker Funeral Home, David Alexander
Address:
3809 Main Street, Warrensburg, New York 12885 Phone: (518) 623-2065
The cremated remains of deceased will be disposed of as follows:
Return to family
If for any reason the person named above does not take possession of the cremated remains,
Pine View Crematory is authorized to give possession of
(Crematory Name)
Alexander-Baker Funeral Home by delivery
the remains to (Funeral Home Name)
in person or by registered mail.
Dawn A. Morrisey
(Name of Deceased)
Page 2 of 3
DOS-1898-f(Rev. 08/15)
Authorization for Cremation and Disposition
(Initial the following)
W GIB'► I/We understand that if the remains are not claimed within 120 days of cremation,
Pine View Crematory may dispose of the remains in
(Name of Crematory)
an irretrievable manner, such as by scattering.
CREMATION CONTAINERIURN
(Initial ONE of the following)
Alexander-Baker Funeral
An urn to be used as a container for the cremated remains has been purchased from Wnmm
and is described as follows:
INVe understand that if the urn is too small to hold the entire cremated remains, an additional rigid container may be used for delivery.
-OR-
W 6101-0 An urn is not yet purchased. INVe understand that if no urn is purchased or otherwise provided
Pine View Crematory will place the cremated remains in
(Name of Crematory)
a rigid temporary container for delivery.
This Authorization Form was provided by David Alexander was executed at
(Funeral Director Name)
Alexander-Baker Funeral Home
(Funeral Home Name)
3809 Main Street, Warrensburg, New York 12885
(Funeral Home Address)
and is signed by the funeral director as witness to its execution.
INVe have received a completed copy of this Authorization Form.
The person(s) identified below is/are the person(s) in control of disposition,who by signing this Authorization Form, attest(s)
to the accuracy and completeness of the information contained in this Authorization Form and authorize(s)the foregoing.
Signed this 14th day of April , 20 20
William C. Morrisey, II �91-� (! -
Typed or Printed Name Signature
36 Olmstedville Road, PO Box 1, Pottersville, NY 12860
Address
Typed or Printed Name Signature
Address
Typed or Printed Name Signature
Address
WITNESS:
David Alexander
(Funeral Director Typed or Printed Name) Fu I or re
10034
(Registration Number)
Dawn A. Morrisey
(Name of Deceased)
DOS-1898-f(Rev. 08/15) Page 3 of 3